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In particular the paper medical record standard 'AS 2828' created by Standards Australia focuses on a few key areas that are critical to maintaining a legible paper medical record. [7] The following criteria should be used as a guideline when creating a medical record specific to the aid of providing clear documentation for diagnostic coding.
Delirium due to ... [indicate the general medical condition] ___._ Delirium due to multiple etiologies: 780.09: Delirium NOS: 297.1: Delusional disorder: 294.1x: Dementia due to ... [indicate the general medical condition not listed above] Coded 294.1 in the DSM-IV. 294.1x: Dementia due to Creutzfeldt-Jakob disease: Coded 290.10 in the DSM-IV ...
607.84 Male erectile disorder due to ... [indicate the general medical condition] 625.0 Female dyspareunia due to ... [indicate the general medical condition] 608.89 Male dyspareunia due to ... [indicate the general medical condition] 625.8 Other female sexual dysfunction due to ... [indicate the general medical condition]
Sortable table Abbreviation Meaning Δ: diagnosis; change: ΔΔ: differential diagnosis (the list of possible diagnoses, and the effort to narrow that list) +ve: positive (as in the result of a test)
The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC codes, like diagnosis-related group (DRG) codes, are primarily a claims and administrative data element unique to the United States medical care reimbursement system. DRG codes also are ...
An alternate, widely used classification publication is the International Classification of Diseases (ICD), produced by the World Health Organization (WHO). [13] The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 6 of the ICD specifically covers mental, behavioral and neurodevelopmental disorders.
Abbrev. [1]Meaning [1] Latin (or Neo-Latin) origin [1]; a.c. before meals: ante cibum a.d., ad, AD right ear auris dextra a.m., am, AM morning: ante meridiem: nocte ...